Annals of Surgical Oncology

, Volume 21, Issue 13, pp 4164–4173 | Cite as

SMO Expression in Colorectal Cancer: Associations with Clinical, Pathological, and Molecular Features

  • Tingting Li
  • Xiaoyun Liao
  • Paul Lochhead
  • Teppei Morikawa
  • Mai Yamauchi
  • Reiko Nishihara
  • Kentaro Inamura
  • Sun A. Kim
  • Kosuke Mima
  • Yasutaka Sukawa
  • Aya Kuchiba
  • Yu Imamura
  • Yoshifumi Baba
  • Kaori Shima
  • Jeffrey A. Meyerhardt
  • Andrew T. Chan
  • Charles S. Fuchs
  • Shuji OginoEmail author
  • Zhi Rong QianEmail author
Colorectal Cancer



Smoothened, frizzled family receptor (SMO) is an important component of the hedgehog signaling pathway, which has been implicated in various human carcinomas. However, clinical, molecular, and prognostic associations of SMO expression in colorectal cancer remain unclear.


Using a database of 735 colon and rectal cancers in the Nurse’s Health Study and the Health Professionals Follow-up Study, we examined the relationship of tumor SMO expression (assessed by immunohistochemistry) to prognosis, and to clinical, pathological, and tumor molecular features, including mutations of KRAS, BRAF, and PIK3CA, microsatellite instability, CpG island methylator phenotype (CIMP), LINE-1 methylation, and expression of phosphorylated AKT and CTNNB1.


SMO expression was detected in 370 tumors (50 %). In multivariate logistic regression analysis, SMO expression was independently inversely associated with phosphorylated AKT expression [odds ratio (OR) 0.48; 95 % confidence interval (CI) 0.34–0.67] and CTNNB1 nuclear localization (OR 0.48; 95 % CI 0.35–0.67). SMO expression was not significantly associated with colorectal cancer-specific or overall survival. However, in CIMP-high tumors, but not CIMP-low/0 tumors, SMO expression was significantly associated with better colorectal cancer-specific survival (log-rank P = 0.012; multivariate hazard ratio, 0.36; 95 % CI 0.13–0.95; P interaction = 0.035, for SMO and CIMP status).


Our data reveal novel potential associations between the hedgehog, the WNT/CTNNB1, and the PI3K (phosphatidylinositol-4,5-bisphosphonate 3-kinase)/AKT pathways, supporting pivotal roles of SMO and hedgehog signaling in pathway networking. SMO expression in colorectal cancer may interact with tumor CIMP status to affect patient prognosis, although confirmation by future studies is needed.


Colorectal Cancer KRAS Mutation BRAF Mutation PIK3CA Mutation Hedgehog Signaling 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Supported in part by USA National Institute of Health (NIH) [P01 CA87969 (to S. E. Hankinson), UM1 CA167552 and P01 CA55075 (to W. C. Willett), R01 CA137178 (to A.T.C.), P50 CA127003 (to C.S.F.), and R01 CA151993 (to S.O.)]; the Bennett Family Fund for Targeted Therapies Research; and the Entertainment Industry Foundation through National Colorectal Cancer Research Alliance. PL was supported by a Harvard University Frank Knox Memorial Fellowship and a fellowship from the Chief Scientist Office, Scotland. A.T.C is a Damon Runyon Clinical Investigator. We would like to thank the participants and staff of the Nurses’ Health Study and the Health Professionals Follow-Up Study for their valuable contributions, as well as the following state cancer registries for their help: AL, AZ, AR, CA, CO, CT, DE, FL, GA, ID, IL, IN, IA, KY, LA, ME, MD, MA, MI, NE, NH, NJ, NY, NC, ND, OH, OK, OR PA, RI, SC, TN, TX, VA, WA, and WY. In addition, this study was approved by the Connecticut Department of Public Health (DPH) Human Investigations Committee. Certain data used in this publication were obtained from the DPH. The authors assume full responsibility for analyses and interpretation of these data. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. Funding agencies did not have any role in the design of the study; the collection, analysis, or interpretation of the data; the decision to submit the article for publication; or the writing of the article.


No potential conflicts of interest exist.


  1. 1.
    Ogino S, Fuchs CS, Giovannucci E. How many molecular subtypes? Implications of the unique tumor principle in personalized medicine. Expert Rev Mol Diagn. 2012;12:621–8.PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Funkhouser WK Jr, Lubin IM, Monzon FA, et al. Relevance, pathogenesis, and testing algorithm for mismatch repair-defective colorectal carcinomas: a report of the association for molecular pathology. J Mol Diagn. 2012;14:91–103.PubMedCrossRefGoogle Scholar
  3. 3.
    Colussi D, Brandi G, Bazzoli F, Ricciardiello L. Molecular pathways involved in colorectal cancer: implications for disease behavior and prevention. Int J Mol Sci. 2013;14:16365–85.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Bardhan K, Liu K. Epigenetics and colorectal cancer pathogenesis. Cancers. 2013;5:676–713.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Kim JH, Kang GH. Molecular and prognostic heterogeneity of microsatellite-unstable colorectal cancer. World J Gastroenterol. 2014;20:4230–43.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Berman DM, Karhadkar SS, Maitra A, et al. Widespread requirement for hedgehog ligand stimulation in growth of digestive tract tumours. Nature. 2003;425:846–51.PubMedCrossRefGoogle Scholar
  7. 7.
    Kolterud A, Grosse AS, Zacharias WJ, et al. Paracrine hedgehog signaling in stomach and intestine: new roles for hedgehog in gastrointestinal patterning. Gastroenterology. 2009;137:618–28.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Fendrich V, Oh E, Bang S, et al. Ectopic overexpression of sonic hedgehog (Shh) induces stromal expansion and metaplasia in the adult murine pancreas. Neoplasia. 2011;13:923–30.PubMedCentralPubMedGoogle Scholar
  9. 9.
    Ng JM, Curran T. The hedgehog’s tale: developing strategies for targeting cancer. Nat Rev Cancer. 2011;11:493–501.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Teglund S, Toftgard R. Hedgehog beyond medulloblastoma and basal cell carcinoma. Biochim Biophys Acta. 2010;1805:181–208.PubMedGoogle Scholar
  11. 11.
    Michael LE, Westerman BA, Ermilov AN, et al. Bmi1 is required for hedgehog pathway-driven medulloblastoma expansion. Neoplasia. 2008;10:1343–9.PubMedCentralPubMedGoogle Scholar
  12. 12.
    Zhang Y, Laterra J, Pomper MG. Hedgehog pathway inhibitor HhAntag691 is a potent inhibitor of ABCG2/BCRP and ABCB1/Pgp. Neoplasia. 2009;11:96–101.PubMedCentralPubMedGoogle Scholar
  13. 13.
    Chatel G, Ganeff C, Boussif N, et al. Hedgehog signaling pathway is inactive in colorectal cancer cell lines. Int J Cancer. 2007;121:2622–7.PubMedCrossRefGoogle Scholar
  14. 14.
    Oniscu A, James RM, Morris RG, Bader S, Malcomson RD, Harrison DJ. Expression of sonic hedgehog pathway genes is altered in colonic neoplasia. J Pathol. 2004;203:909–17.PubMedCrossRefGoogle Scholar
  15. 15.
    Qualtrough D, Buda A, Gaffield W, Williams AC, Paraskeva C. Hedgehog signalling in colorectal tumour cells: induction of apoptosis with cyclopamine treatment. Int J Cancer. 2004;110:831–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Alinger B, Kiesslich T, Datz C, et al. Hedgehog signaling is involved in differentiation of normal colonic tissue rather than in tumor proliferation. Virchows Arch. 2009;454:369–79.PubMedCrossRefGoogle Scholar
  17. 17.
    Mazumdar T, DeVecchio J, Shi T, Jones J, Agyeman A, Houghton JA. Hedgehog signaling drives cellular survival in human colon carcinoma cells. Cancer Res. 2011;71:1092–102.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Varnat F, Duquet A, Malerba M, et al. Human colon cancer epithelial cells harbour active HEDGEHOG-GLI signalling that is essential for tumour growth, recurrence, metastasis and stem cell survival and expansion. EMBO Mol Med. 2009;1:338–51.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Saqui-Salces M, Merchant JL. Hedgehog signaling and gastrointestinal cancer. Biochim Biophys Acta. 2010;1803:786–95.PubMedCrossRefGoogle Scholar
  20. 20.
    Akiyoshi T, Nakamura M, Koga K, et al. Gli1, downregulated in colorectal cancers, inhibits proliferation of colon cancer cells involving Wnt signalling activation. Gut. 2006;55:991–9.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Ding YL, Wang QS, Zhao WM, Xiang L. Expression of smoothened protein in colon cancer and its prognostic value for postoperative liver metastasis. Asian Pac J Cancer Prev. 2012;13:4001–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Arimura S, Matsunaga A, Kitamura T, Aoki K, Aoki M, Taketo MM. Reduced level of smoothened suppresses intestinal tumorigenesis by down-regulation of Wnt signaling. Gastroenterology. 2009;137:629–38.PubMedCrossRefGoogle Scholar
  23. 23.
    Morris JPT, Wang SC, Hebrok M. KRAS, hedgehog, Wnt and the twisted developmental biology of pancreatic ductal adenocarcinoma. Nat Rev Cancer. 2010;10:683–95.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Riobo NA, Lu K, Ai X, Haines GM, Emerson CP Jr. Phosphoinositide 3-kinase and Akt are essential for sonic hedgehog signaling. Proc Natl Acad Sci USA. 2006;103:4505–10.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Madhala-Levy D, Williams VC, Hughes SM, Reshef R, Halevy O. Cooperation between Shh and IGF-I in promoting myogenic proliferation and differentiation via the MAPK/ERK and PI3K/Akt pathways requires Smo activity. J Cell Physiol. 2012;227:1455–64.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Yoo YA, Kang MH, Lee HJ, et al. Sonic hedgehog pathway promotes metastasis and lymphangiogenesis via activation of Akt, EMT, and MMP-9 pathway in gastric cancer. Cancer Res. 2011;71:7061–70.PubMedCrossRefGoogle Scholar
  27. 27.
    Ogino S, Stampfer M. Lifestyle factors and microsatellite instability in colorectal cancer: the evolving field of molecular pathological epidemiology. J Natl Cancer Inst. 2010;102:365–7.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Ogino S, Chan AT, Fuchs CS, Giovannucci E. Molecular pathological epidemiology of colorectal neoplasia: an emerging transdisciplinary and interdisciplinary field. Gut. 2011;60:397–411.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Liao X, Lochhead P, Nishihara R, et al. Aspirin use, tumor PIK3CA mutation, and colorectal-cancer survival. N Engl J Med. 2012;367:1596–606.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Yamauchi M, Morikawa T, Kuchiba A, et al. Assessment of colorectal cancer molecular features along bowel subsites challenges the conception of distinct dichotomy of proximal versus distal colorectum. Gut. 2012;61:847–54.PubMedCentralPubMedCrossRefGoogle Scholar
  31. 31.
    Chan AT, Ogino S, Fuchs CS. Aspirin and the risk of colorectal cancer in relation to the expression of COX-2. N Engl J Med. 2007;356:2131–42.PubMedCrossRefGoogle Scholar
  32. 32.
    Kawasaki T, Nosho K, Ohnishi M, et al. IGFBP3 promoter methylation in colorectal cancer: relationship with microsatellite instability, CpG island methylator phenotype, and p53. Neoplasia. 2007;9:1091–8.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Baba Y, Nosho K, Shima K, et al. Phosphorylated AKT expression is associated with PIK3CA mutation, low stage, and favorable outcome in 717 colorectal cancers. Cancer. 2011;117:1399–408.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Morikawa T, Kuchiba A, Yamauchi M, et al. Association of CTNNB1 (beta-catenin) alterations, body mass index, and physical activity with survival in patients with colorectal cancer. JAMA. 2011;305:1685–94.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Dierks C, Grbic J, Zirlik K, et al. Essential role of stromally induced hedgehog signaling in B-cell malignancies. Nat Med. 2007;13:944–51.PubMedCrossRefGoogle Scholar
  36. 36.
    Riobo NA, Saucy B, Dilizio C, Manning DR. Activation of heterotrimeric G proteins by smoothened. Proc Natl Acad Sci USA. 2006;103:12607–12.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Gerber AN, Wilson CW, Li YJ, Chuang PT. The hedgehog regulated oncogenes Gli1 and Gli2 block myoblast differentiation by inhibiting MyoD-mediated transcriptional activation. Oncogene. 2007;26:1122–36.PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Liao X, Siu MK, Au CW, et al. Aberrant activation of hedgehog signaling pathway in ovarian cancers: effect on prognosis, cell invasion and differentiation. Carcinogenesis. 2009;30:131–40.PubMedCrossRefGoogle Scholar
  39. 39.
    Imamura Y, Morikawa T, Liao X, et al. Specific mutations in KRAS codons 12 and 13, and patient prognosis in 1075 BRAF wild-type colorectal cancers. Clin Cancer Res. 2012;18:4753–63.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Ogino S, Kawasaki T, Kirkner GJ, Loda M, Fuchs CS. CpG island methylator phenotype-low (CIMP-low) in colorectal cancer: possible associations with male sex and KRAS mutations. J Mol Diagn. 2006;8:582–8.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Ogino S, Nosho K, Kirkner GJ, et al. CpG island methylator phenotype, microsatellite instability, BRAF mutation and clinical outcome in colon cancer. Gut. 2009;58:90–6.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Liao X, Morikawa T, Lochhead P, et al. Prognostic role of PIK3CA mutation in colorectal cancer: cohort study and literature review. Clin Cancer Res. 2012;18:2257–68.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Hinoue T, Weisenberger DJ, Lange CP, et al. Genome-scale analysis of aberrant DNA methylation in colorectal cancer. Genome Res. 2012;22:271–82.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Ogino S, Kawasaki T, Brahmandam M, et al. Precision and performance characteristics of bisulfite conversion and real-time PCR (MethyLight) for quantitative DNA methylation analysis. J Mol Diagn. 2006;8:209–17.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Ogino S, Kawasaki T, Nosho K, et al. LINE-1 hypomethylation is inversely associated with microsatellite instability and CpG island methylator phenotype in colorectal cancer. Int J Cancer. 2008;122:2767–73.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Ogino S, Nosho K, Kirkner GJ, et al. A cohort study of tumoral LINE-1 hypomethylation and prognosis in colon cancer. J Natl Cancer Inst. 2008;100:1734–8.PubMedCentralPubMedCrossRefGoogle Scholar
  47. 47.
    Ogino S, Goel A. Molecular classification and correlates in colorectal cancer. J Mol Diagn. 2008;10:13–27.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Cancer Genome Atlas Network. Comprehensive molecular characterization of human colon and rectal cancer. Nature. 2012;487:330–7.CrossRefGoogle Scholar
  49. 49.
    Wang D, Xia D, Dubois RN. The crosstalk of PTGS2 and EGF signaling pathways in colorectal cancer. Cancers. 2011;3:3894–908.PubMedCentralPubMedCrossRefGoogle Scholar
  50. 50.
    Bertrand FE, Angus CW, Partis WJ, Sigounas G. Developmental pathways in colon cancer: crosstalk between WNT, BMP, hedgehog and Notch. Cell Cycle. 2012;11:4344–51.PubMedCentralPubMedCrossRefGoogle Scholar
  51. 51.
    Leggett B, Whitehall V. Role of the serrated pathway in colorectal cancer pathogenesis. Gastroenterology. 2010;138:2088–100.PubMedCrossRefGoogle Scholar
  52. 52.
    Rosty C, Hewett DG, Brown IS, Leggett BA, Whitehall VL. Serrated polyps of the large intestine: current understanding of diagnosis, pathogenesis, and clinical management. J Gastroenterol. 2013;48:287–302.PubMedCentralPubMedCrossRefGoogle Scholar
  53. 53.
    Domingo E, Ramamoorthy R, Oukrif D, et al. Use of multivariate analysis to suggest a new molecular classification of colorectal cancer. J Pathol. 2013;229:441–8.PubMedCentralPubMedCrossRefGoogle Scholar
  54. 54.
    Hayashi Y, Molina JR, Hamilton SR, Georgescu MM. NHERF1/EBP50 is a new marker in colorectal cancer. Neoplasia. 2010;12:1013–22.PubMedCentralPubMedGoogle Scholar
  55. 55.
    Soerjomataram I, Thong MS, Korfage IJ, et al. Excess weight among colorectal cancer survivors: target for intervention. J Gastroenterol. 2012;47:999–1005.PubMedCentralPubMedCrossRefGoogle Scholar
  56. 56.
    Wu KL, Huang EY, Jhu EW, et al. Overexpression of galectin-3 enhances migration of colon cancer cells related to activation of the K-Ras-Raf-Erk1/2 pathway. J Gastroenterol. 2013;48:350–9.PubMedCrossRefGoogle Scholar
  57. 57.
    Engelman JA. Targeting PI3K signalling in cancer: opportunities, challenges and limitations. Nat Rev Cancer. 2009;9:550–62.PubMedCrossRefGoogle Scholar
  58. 58.
    van den Brink GR, Bleuming SA, Hardwick JC, et al. Indian hedgehog is an antagonist of Wnt signaling in colonic epithelial cell differentiation. Nat Genet. 2004;36:277–82.PubMedCrossRefGoogle Scholar
  59. 59.
    Toyota M, Ahuja N, Ohe-Toyota M, Herman JG, Baylin SB, Issa JP. CpG island methylator phenotype in colorectal cancer. Proc Natl Acad Sci USA. 1999;96:8681–6.PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    Beggs AD, Jones A, El-Bahrawy M, Abulafi M, Hodgson SV, Tomlinson IP. Whole-genome methylation analysis of benign and malignant colorectal tumours. J Pathol. 2013;229:697–704.PubMedCentralPubMedCrossRefGoogle Scholar
  61. 61.
    Yang Q, Dong Y, Wu W, et al. Detection and differential diagnosis of colon cancer by a cumulative analysis of promoter methylation. Nat Commun. 2012;3:1206.PubMedCrossRefGoogle Scholar
  62. 62.
    Dahlin AM, Palmqvist R, Henriksson ML, et al. The role of the CpG island methylator phenotype in colorectal cancer prognosis depends on microsatellite instability screening status. Clin Cancer Res. 2010;16:1845–55.PubMedCrossRefGoogle Scholar
  63. 63.
    Zlobec I, Bihl M, Foerster A, Rufle A, Lugli A. Comprehensive analysis of CpG island methylator phenotype (CIMP)-high, -low, and -negative colorectal cancers based on protein marker expression and molecular features. J Pathol. 2011;225:336–43.PubMedCrossRefGoogle Scholar
  64. 64.
    Lao VV, Grady WM. Epigenetics and colorectal cancer. Nat Rev Gastroenterol Hepatol. 2011;8:686–700.PubMedCentralPubMedCrossRefGoogle Scholar
  65. 65.
    Hughes LA, Bakker CA, Smits KM, et al. The CpG island methylator phenotype in colorectal cancer: progress and problems. Biochim Biophys Acta. 2012;1825:77–85.PubMedGoogle Scholar
  66. 66.
    Price TJ, Hardingham JE, Lee CK, et al. Impact of KRAS and BRAF gene mutation status on outcomes from the phase III AGITG MAX trial of capecitabine alone or in combination with bevacizumab and mitomycin in advanced colorectal cancer. J Clin Oncol. 2011;29:2675–82.PubMedCrossRefGoogle Scholar
  67. 67.
    Ogino S, Shima K, Meyerhardt JA, et al. Predictive and prognostic roles of BRAF mutation in stage III colon cancer: results from intergroup trial CALGB 89803. Clin Cancer Res. 2012;18:890–900.PubMedCentralPubMedCrossRefGoogle Scholar
  68. 68.
    Samowitz WS, Sweeney C, Herrick J, et al. Poor survival associated with the BRAF V600E mutation in microsatellite-stable colon cancers. Cancer Res. 2005;65:6063–9.PubMedCrossRefGoogle Scholar
  69. 69.
    Lochhead P, Kuchiba A, Imamura Y, et al. Microsatellite instability and BRAF mutation testing in colorectal cancer prognostication. J Natl Cancer Inst. 2013;105:1151–6.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Tingting Li
    • 1
    • 2
  • Xiaoyun Liao
    • 1
  • Paul Lochhead
    • 1
  • Teppei Morikawa
    • 3
  • Mai Yamauchi
    • 1
  • Reiko Nishihara
    • 1
    • 4
  • Kentaro Inamura
    • 1
    • 5
  • Sun A. Kim
    • 1
  • Kosuke Mima
    • 1
  • Yasutaka Sukawa
    • 1
  • Aya Kuchiba
    • 1
    • 4
  • Yu Imamura
    • 1
  • Yoshifumi Baba
    • 6
  • Kaori Shima
    • 7
  • Jeffrey A. Meyerhardt
    • 1
  • Andrew T. Chan
    • 8
  • Charles S. Fuchs
    • 1
    • 9
  • Shuji Ogino
    • 1
    • 10
    • 11
    Email author
  • Zhi Rong Qian
    • 1
    Email author
  1. 1.Department of Medical OncologyDana-Farber Cancer Institute and Harvard Medical SchoolBostonUSA
  2. 2.Department of Geriatric GastroenterologyChinese PLA General HospitalBeijingChina
  3. 3.Department of PathologyUniversity of Tokyo HospitalTokyoJapan
  4. 4.Department of NutritionHarvard School of Public HealthBostonUSA
  5. 5.Laboratory of Human Carcinogenesis, National Cancer InstituteNational Institutes of HealthBethesdaUSA
  6. 6.Department of Gastroenterological SurgeryKumamoto UniversityKumamotoJapan
  7. 7.Department of Oral PathologyKagoshima UniversityKagoshimaJapan
  8. 8.Gastrointestinal UnitMassachusetts General HospitalBostonUSA
  9. 9.Channing Division of Network Medicine, Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonUSA
  10. 10.Department of PathologyBrigham and Women’s HospitalBostonUSA
  11. 11.Department of EpidemiologyHarvard School of Public HealthBostonUSA

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